Dr Qamar Ghafoor is a Consultant Clinical Oncologist at University Hospital Birmingham (UHB) and leads the new mesothelioma multidisciplinary team (MDT) set up in October 2017. The MDT brings together specialist experts in mesothelioma including oncologists, surgeons, chest physicians, lung cancer nurses, occupational physicians, pathologists, radiologists and palliative care nurses who look at diagnosis and treatment options for mesothelioma patients. We asked Dr Ghafoor about the MDT, access to clinical trials and immunotherapy treatment in the West Midlands.

Why did you feel there was a need for a specialist mesothelioma MDT in the West Midlands?

We realised that the outcomes for mesothelioma patients were the worst in the West Midlands compared to the rest of the country. For example, in the West Midlands only 26.8% of mesothelioma patients received chemotherapy but in Greater Manchester that number was higher at 55.4%. We realised on a number of different fronts we had the lowest statistics compared to other regions. Mesothelioma patients in the West Midlands were being referred to the specialist MDT at Leicester so we decided we needed to give patients access to medical expertise locally. It took two years of planning to set up the mesothelioma MDT. University Hospital Birmingham Charities has agreed to fund the MDT for a 6 month pilot during which we have to show that the MDT is feasible.

How has the MDT benefited mesothelioma patients so far?
It is early days but initially, we were seeing 2 to 3 mesothelioma cases but we are now seeing 7-8 mesothelioma cases per MDT. We’ve made a number of changes to how we work including how we review histology and how mesothelioma patients can access clinical trials. So far, 45-50% of mesothelioma patients have been referred for clinical trials in Leicester or London. Having a specialist MDT means that we can be firmer on diagnosis and treatment options for mesothelioma patients.

What are the ambitions of the MDT?
Our ambition is very simple. We want to ensure mesothelioma patients in the West Midlands have equal, if not better, access to expertise, care and treatment options . We want to improve outcomes for mesothelioma patients. We also want to develop expertise locally so that patients don’t have to be referred to other hospitals outside of the West Midlands. We are learning as we’re going along and finding better ways to feed information back to health professionals looking after mesothelioma patients. It’s great that we’ve got good links with for example Leicester because if we have any queries or concerns we can work together on resolving them.

We went on to ask Dr Ghafoor about immunotherapy treatment in mesothelioma cases.

What is your experience of immunotherapy treatment in lung cancer cases?
I’ve administered immunotherapy treatment in 25-30 lung cancer patients and I have seen some good responses. A significant proportion of those patients responded well to immunotherapy treatment and a number of them lived beyond two years. I have a number of patients with lung cancer who are well clinically and have good quality of life.

What about immunotherapy in mesothelioma cases?
The number of mesothelioma patients who have received immunotherapy treatment at UHB are low. Immunotherapy treatment for mesothelioma patients isn’t available on the NHS and has to be paid for privately. Currently there are trials taking place looking at the response mesothelioma patients have to immunotherapy treatment. The data from the Keynote-28 trial looking at Pembrolizumab immunotherapy for mesothelioma is promising in terms of tumour shrinkage and stable disease. It is early days but the data shows that some mesothelioma patients are having a durable response to immunotherapy treatment. Further clinical data from the ongoing studies is awaited before we know if it is suitable treatment for mesothelioma patients. At UHB we are keen to participate in the clinical trials so that there is clinical evidence of the impact of immunotherapy treatment in mesothelioma patients. Immunotherapy treatment offers a different approach to chemotherapy treatment. Once a mesothelioma patient has had chemotherapy, the options for further treatment are not great so if immunotherapy is suitable treatment then it should be available.

In your view which patients are suitable for immunotherapy treatment?
My view is that it is suitable for everyone. There is a school of thought that you need high PDL1 expression because that improves your chances of a good response. My personal view is that everyone should have access to immunotherapy treatment with an early assessment of whether or not that person is responding to treatment.

Are there any circumstances in which you would not recommend immunotherapy to a mesothelioma patient?
If the person has any contra-indications to immunotherapy treatment, for example is suffering from auto-immune disease or has a poor performance status then they wouldn’t be suitable for immunotherapy treatment.

Would you recommend immunotherapy treatment for someone who hasn’t had chemotherapy treatment in the first instance?
No because chemotherapy is the accepted form of treatment in mesothelioma cases because we have clinical evidence that it works. I don’t think we should be using immunotherapy treatment as first-line treatment until we have better clinical evidence from the immunotherapy trials.

Practically, how does someone receive immunotherapy treatment?
The day before the patient receives immunotherapy treatment they come to the hospital for a blood test. On the day of treatment the patient is taken to a ward, a drip is inserted into them and the medication is delivered over 30 to 60 minute period. Once this is done the patient can go home. Treatment takes places usually every 3 weeks. A CT scan takes place every 3 months. It is a straightforward and quick procedure. Immunotherapy treatment can take place in a hospital or in the community. Patients continue to receive the treatment until the disease shows signs of progression. When assessing if there has been progression of the disease we look at the patient’s symptoms as well as look at the CT scan. Sometimes the CT scan can show what we call ‘pseudo-progression’. When a person receives immunotherapy treatment the body creates cells to kill the cancer. A CT scan can’t differentiate between these cells and cancer cells so a scan may show progression but the patient may feel very well so we have to look at a combination of the two.

What advice would you give to a mesothelioma patient who wants to find out more about immunotherapy treatment?
I would say speak to your lung cancer nurse specialist, your treating physician or oncologist or liaise with the multidisciplinary team. We can then discuss this with you.

What would you say is the main obstacle to having immunotherapy treatment in mesothelioma cases?
The fact that the clinical data is in its early stages is the main obstacle. We need more clinical data to know that immunotherapy treatment is the right treatment in mesothelioma cases.

What is your hope with immunotherapy treatment?
I hope it is suitable treatment for mesothelioma patients and is available to all. It is a terrible illness, often caused by someone’s work so the patient should have all available treatment options. I hope immunotherapy offers durable quantity as well as quality of life for patients.

Does having the MDT in Birmingham assist or hinder treatment options?
It will assist because by having the MDT as we can make sure that we have unifying treatment across the region as well as access to knowledge and expertise. We accept and recognise that the outcomes in the West Midlands for mesothelioma patients have been poor compared to the rest of the country. Our plan is that in the long term the outcomes will be better than the rest of the country. At the end of the six-month period we should be in a position to show that having the MDT in Birmingham has not just improved patient care but also improved access to clinical trials.